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Elderly Drivers with Cognitive Impairment

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181. Amyotrophic Lateral Sclerosis (Follow-up)

sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology . 2009 Oct 13. 73(15):1227-1233. . . Hardiman O, van den Berg LH, Kiernan MC. Clinical diagnosis and management of amyotrophic lateral sclerosis. Nat Rev Neurol . 2011 Oct 11. 7(11):639-49. . King SJ, Duke MM, O'Connor BA. Living with amyotrophic lateral sclerosis/motor neurone disease (ALS/MND (...) greater efficacy for riluzole in clinical practice than in the clinical trial. However, the relevance of these claims has been challenged [ ] because the reports pit class IV evidence against class I evidence, which is contrary to the usual evidence-based approach used to judge treatment efficacy. Prognosis Patients with ALS who have depression, frontotemporal dementia (FTD), or a milder level of frontal impairment are now recognized as less likely to accept treatment recommendations and have a poorer

2014 eMedicine.com

182. Cancer and Rehabilitation (Overview)

tumor progression and treatment causes a functional decline or when the disease causes a fluctuation in abilities, rehabilitation assumes a supportive role, and its goals are adjusted to accommodate the patient's persistent anatomic and physiologic limitation. Thorough assessment of cognitive dysfunction, physical impairments, disabilities, and handicaps is paramount before the team proceeds with rehabilitation. Emphasis is initially placed on restoring or maximizing independence with ADLs, mobility (...) , rehabilitation for cancer-related disability is an underutilized resource. [ , , ] Reasons for underutilization are multidimensional. Cancer-related symptoms often have gradual onset, and patients may be hesitant to tell their oncologist about issues such as deconditioning, poor balance, impaired mobility, pain, poor nutrition, decreased cognitive function, and altered self-image. [ , ] Furthermore, oncologists may not be in the habit of specifically asking about these impairments. Movsas et al confirmed

2014 eMedicine.com

183. Assistive Devices to Improve Independence (Overview)

. Depression is common in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. [ ] Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society. See the images below. Driver's evaluation. Steps in testing for reaction time (...) that a patient over the age of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly. Not all hearing impairments are reversible. Examples of impairments that are potentially reversible

2014 eMedicine.com

184. Rhinitis, Allergic (Diagnosis)

significantly impair quality of life, [ , ] which leads to a number of indirect costs. The total direct and indirect cost of allergic rhinitis was recently estimated to be $5.3 billion per year. [ ] A 2011 analysis determined that patients with allergic rhinitis averaged 3 additional office visits, 9 more prescriptions filled, and $1500 in incremental healthcare costs in 1 year than similar patients without allergic rhinitis. [ ] See , a Critical Images slideshow, to help identify a variety of allergens (...) to impaired quality of life. Previous Next: Epidemiology Frequency United States The prevalence of allergic rhinitis in the United States ranges from 3% to 19%, and 30 to 60 million people are affected each year. The development of allergic rhinitis before 20 years of age occurs in 80% of cases. [ ] In 2012, 9% of children younger than 18 years and 7.5% of adults reported allergic rhinitis in the past 12 months. [ ] International Throughout the world, the prevalence of allergic rhinitis has slightly

2014 eMedicine.com

185. Geriatric Rehabilitation (Diagnosis)

in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. [ ] Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society. See the images below. Driver's evaluation. Steps in testing for reaction time. Driver's evaluation (...) of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly. Not all hearing impairments are reversible. Examples of impairments that are potentially reversible involve cerumen

2014 eMedicine.com

186. Cancer and Rehabilitation (Diagnosis)

tumor progression and treatment causes a functional decline or when the disease causes a fluctuation in abilities, rehabilitation assumes a supportive role, and its goals are adjusted to accommodate the patient's persistent anatomic and physiologic limitation. Thorough assessment of cognitive dysfunction, physical impairments, disabilities, and handicaps is paramount before the team proceeds with rehabilitation. Emphasis is initially placed on restoring or maximizing independence with ADLs, mobility (...) , rehabilitation for cancer-related disability is an underutilized resource. [ , , ] Reasons for underutilization are multidimensional. Cancer-related symptoms often have gradual onset, and patients may be hesitant to tell their oncologist about issues such as deconditioning, poor balance, impaired mobility, pain, poor nutrition, decreased cognitive function, and altered self-image. [ , ] Furthermore, oncologists may not be in the habit of specifically asking about these impairments. Movsas et al confirmed

2014 eMedicine.com

187. Assistive Devices to Improve Independence (Diagnosis)

. Depression is common in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. [ ] Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society. See the images below. Driver's evaluation. Steps in testing for reaction time (...) that a patient over the age of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly. Not all hearing impairments are reversible. Examples of impairments that are potentially reversible

2014 eMedicine.com

188. Rhinitis, Allergic (Treatment)

events. Sublingual Sublingual immunotherapy (SLIT) is currently increasing in use, particularly in Europe. Differences between SLIT and subcutaneous immunotherapy (SCIT) need further study, including research on differences in efficacy, durability, and safety. SLIT can produce significant clinical improvement in elderly patients with allergic rhinitis caused by house dust mites (HDMs), according to a study by Bozek et al. The report looked at a group of patients aged 60-75 years with allergic (...) or clarification of specific allergic triggers is needed, when detailed counseling regarding environmental control measures is needed, when quality of life is significantly impaired, or when immunotherapy may be a consideration. Previous References Druce HM. Allergic and nonallergic rhinitis. Middleton EM Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy: Principles and Practice . 5th ed. St. Louis, Mo: Mosby Year-Book; 1998. 1005-16. Togias AG. Systemic immunologic and inflammatory

2014 eMedicine.com

189. Obstructive Sleep Apnea (Treatment)

and/or hypopnea, oxyhemoglobin desaturation, RERAs, and snoring from sleep. It also results in adequate sleep continuity. CPAP has been shown to improve daytime sleepiness, mood, and cognitive function in people with both mild and moderate apnea. [ , ] CPAP has also been shown to decrease blood pressure, primarily in patients with severe OSA. [ , , ] Evidence also indicates that it may improve the left ventricular ejection fraction in patients with congestive heart failure and OSA. [ ] CPAP plus (...) adherent patients should be asked about mask fit, mask leak, sinus/nasal congestion, mouth breathing, and general sleep habits to determine reasons for nonadherence. Interventions to improve compliance include (1) attendance in a group clinic with education provided, (2) group cognitive behavioral therapy provided as two 1-hour sessions that include an educational talk and video of real CPAP users, (3) written literature and weekly phone calls during the first month of use, (4) use of nasal

2014 eMedicine.com

190. Amyotrophic Lateral Sclerosis (Treatment)

sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology . 2009 Oct 13. 73(15):1227-1233. . . Hardiman O, van den Berg LH, Kiernan MC. Clinical diagnosis and management of amyotrophic lateral sclerosis. Nat Rev Neurol . 2011 Oct 11. 7(11):639-49. . King SJ, Duke MM, O'Connor BA. Living with amyotrophic lateral sclerosis/motor neurone disease (ALS/MND (...) greater efficacy for riluzole in clinical practice than in the clinical trial. However, the relevance of these claims has been challenged [ ] because the reports pit class IV evidence against class I evidence, which is contrary to the usual evidence-based approach used to judge treatment efficacy. Prognosis Patients with ALS who have depression, frontotemporal dementia (FTD), or a milder level of frontal impairment are now recognized as less likely to accept treatment recommendations and have a poorer

2014 eMedicine.com

191. Insomnia (Treatment)

include long-acting forms (eg, flurazepam, quazepam), intermediate-acting forms (eg, temazepam, estazolam), and short-acting forms (triazolam). The long-acting agents are rarely used today for insomnia because of daytime sedation, cognitive impairment, and increased risk of falls in elderly patients. Benzodiazepines were commonly used until the 1980s, when tolerance, dependence, and daytime side effects were recognized as major limitations of these agents, particularly those with long elimination half (...) enough to impair these activities. [ , ] Eszopiclone has a half-life of 5-7 hours and can be used for sleep-maintenance insomnia. The starting dose is 1 mg immediately before bedtime, with at least 7-8 hours remaining before the planned time of awakening. The dose may be increased if clinically warranted to 2-3 mg HS in nonelderly adults, and 2 mg in elderly or debilitated patients. Next-day impairment can occur after taking after a starting dose of 2 mg. FDA findings from observing 91 healthy adults

2014 eMedicine.com

192. Cancer and Rehabilitation (Treatment)

tumor progression and treatment causes a functional decline or when the disease causes a fluctuation in abilities, rehabilitation assumes a supportive role, and its goals are adjusted to accommodate the patient's persistent anatomic and physiologic limitation. Thorough assessment of cognitive dysfunction, physical impairments, disabilities, and handicaps is paramount before the team proceeds with rehabilitation. Emphasis is initially placed on restoring or maximizing independence with ADLs, mobility (...) , rehabilitation for cancer-related disability is an underutilized resource. [ , , ] Reasons for underutilization are multidimensional. Cancer-related symptoms often have gradual onset, and patients may be hesitant to tell their oncologist about issues such as deconditioning, poor balance, impaired mobility, pain, poor nutrition, decreased cognitive function, and altered self-image. [ , ] Furthermore, oncologists may not be in the habit of specifically asking about these impairments. Movsas et al confirmed

2014 eMedicine.com

193. Pathophysiology of Chronic Back Pain (Treatment)

intervertebral disk may impair the resolution of some persistent painful cases of chronic LBP (cLBP). An estimated 15-20% develop protracted pain, and approximately 2-8% have chronic pain. Of those individuals who remain disabled for more than 6 months, fewer than half return to work, and after 2 years of LBP disability, a return to work is even more unlikely. [ ] Studies suggest that one third to one fourth of patients in a primary care setting may still have problems after 1 year. [ , ] cLBP is the most (...) —a staggering 500,000 cases. LBP accounts for 19% of all workers' compensation claims in the United States. According to the Bureau of Labor and Statistics, metal workers generate 76% of all claims of back strain and/or sprains. Jobs that require heavy manual labor and material-handling activities account for more than half of all back pain reports. Injuries to the back are highest among truck drivers, operators of heavy equipment, and construction workers. From 1971-1981, the number of Americans disabled

2014 eMedicine.com

194. Obstructive Sleep Apnea-Hypopnea Syndrome (Treatment)

and/or hypopnea, oxyhemoglobin desaturation, RERAs, and snoring from sleep. It also results in adequate sleep continuity. CPAP has been shown to improve daytime sleepiness, mood, and cognitive function in people with both mild and moderate apnea. [ , ] CPAP has also been shown to decrease blood pressure, primarily in patients with severe OSA. [ , , ] Evidence also indicates that it may improve the left ventricular ejection fraction in patients with congestive heart failure and OSA. [ ] CPAP plus (...) adherent patients should be asked about mask fit, mask leak, sinus/nasal congestion, mouth breathing, and general sleep habits to determine reasons for nonadherence. Interventions to improve compliance include (1) attendance in a group clinic with education provided, (2) group cognitive behavioral therapy provided as two 1-hour sessions that include an educational talk and video of real CPAP users, (3) written literature and weekly phone calls during the first month of use, (4) use of nasal

2014 eMedicine.com

195. Rhinitis, Allergic (Overview)

significantly impair quality of life, [ , ] which leads to a number of indirect costs. The total direct and indirect cost of allergic rhinitis was recently estimated to be $5.3 billion per year. [ ] A 2011 analysis determined that patients with allergic rhinitis averaged 3 additional office visits, 9 more prescriptions filled, and $1500 in incremental healthcare costs in 1 year than similar patients without allergic rhinitis. [ ] See , a Critical Images slideshow, to help identify a variety of allergens (...) to impaired quality of life. Previous Next: Epidemiology Frequency United States The prevalence of allergic rhinitis in the United States ranges from 3% to 19%, and 30 to 60 million people are affected each year. The development of allergic rhinitis before 20 years of age occurs in 80% of cases. [ ] In 2012, 9% of children younger than 18 years and 7.5% of adults reported allergic rhinitis in the past 12 months. [ ] International Throughout the world, the prevalence of allergic rhinitis has slightly

2014 eMedicine.com

196. Pathophysiology of Chronic Back Pain (Overview)

intervertebral disk may impair the resolution of some persistent painful cases of chronic LBP (cLBP). An estimated 15-20% develop protracted pain, and approximately 2-8% have chronic pain. Of those individuals who remain disabled for more than 6 months, fewer than half return to work, and after 2 years of LBP disability, a return to work is even more unlikely. [ ] Studies suggest that one third to one fourth of patients in a primary care setting may still have problems after 1 year. [ , ] cLBP is the most (...) —a staggering 500,000 cases. LBP accounts for 19% of all workers' compensation claims in the United States. According to the Bureau of Labor and Statistics, metal workers generate 76% of all claims of back strain and/or sprains. Jobs that require heavy manual labor and material-handling activities account for more than half of all back pain reports. Injuries to the back are highest among truck drivers, operators of heavy equipment, and construction workers. From 1971-1981, the number of Americans disabled

2014 eMedicine.com

197. Geriatric Rehabilitation (Overview)

in the older population if a functional loss of mobility and an inability to perform activities of daily living (ADLs) predominates. [ ] Cognitive impairment, such as delirium and dementia, can affect the patient's rehabilitation goals and outcomes. Finally, a driver's evaluation for an appropriate elderly candidate is an underutilized part of rehabilitation that has a considerable impact on society. See the images below. Driver's evaluation. Steps in testing for reaction time. Driver's evaluation (...) of 65 years has significant hearing loss is 25-50%. The prevalence of hearing loss increases to 50% in people older than 75 years. The geriatric population is growing, and in the near future, the number of geriatric patients experiencing severe sensory loss is likely to increase. Poor vision, a high level of comorbidity, and depression are related to hearing loss in the elderly. Not all hearing impairments are reversible. Examples of impairments that are potentially reversible involve cerumen

2014 eMedicine.com

198. Head Injury (Overview)

with longer durations of posttraumatic amnesia have poorer outcomes. [ ] In the long-term setting, the following bedside cognitive tests can be employed: Mini-Mental State Examination Luria "fist, chop, slap" sequencing task: To rapidly assess motor regulation Antisaccade task: Impaired in patients with symptomatic brain injury; the sensitivity of this test in detecting brain injury has been questioned [ ] Letter and category fluency: To provide information about self-generative frontal processes. Untimed (...) studies suggested that elevated serum levels may correlate with persistent cognitive impairment at 6 months in patients with severe or mild head injuries, current opinion considers these tests no longer useful. [ , ] In 2018, a commercially available blood test for mild brain injury was approved by the FDA. [ ] This test reportedly identifies 98% of patients with abnormal head CT scans. Imaging studies Computed tomography scanning: The main imaging modality used in the acute setting Magnetic resonance

2014 eMedicine.com

199. Head Injury (Treatment)

study. AJNR Am J Neuroradiol . 2008 Mar. 29(3):514-9. . Niogi SN, Mukherjee P, Ghajar J, Johnson C, Kolster RA, Sarkar R. Extent of microstructural white matter injury in postconcussive syndrome correlates with impaired cognitive reaction time: a 3T diffusion tensor imaging study of mild traumatic brain injury. AJNR Am J Neuroradiol . 2008 May. 29(5):967-73. . Dailey NS, Smith R, Bajaj S, Alkozei A, Gottschlich MK, Raikes AC, et al. Elevated Aggression and Reduced White Matter Integrity in Mild (...) this substance. [ ] Rosuvastatin given in the acute phase of moderate head injury significantly reduced amnesia in a double-blind placebo-controlled study of 34 patients. [ ] Other research has retrospectively found that statin use was associated with a decreased mortality in a large, 100,515 patient cohort of brain injured elderly. [ ] Furthermore, a randomized prospective trial of atorvastatin demonstated improved functional outcomes at 3 months post-injury in patients with brain contusions who were

2014 eMedicine.com

200. Insomnia (Treatment)

include long-acting forms (eg, flurazepam, quazepam), intermediate-acting forms (eg, temazepam, estazolam), and short-acting forms (triazolam). The long-acting agents are rarely used today for insomnia because of daytime sedation, cognitive impairment, and increased risk of falls in elderly patients. Benzodiazepines were commonly used until the 1980s, when tolerance, dependence, and daytime side effects were recognized as major limitations of these agents, particularly those with long elimination half (...) enough to impair these activities. [ , ] Eszopiclone has a half-life of 5-7 hours and can be used for sleep-maintenance insomnia. The starting dose is 1 mg immediately before bedtime, with at least 7-8 hours remaining before the planned time of awakening. The dose may be increased if clinically warranted to 2-3 mg HS in nonelderly adults, and 2 mg in elderly or debilitated patients. Next-day impairment can occur after taking after a starting dose of 2 mg. FDA findings from observing 91 healthy adults

2014 eMedicine.com

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